
<h2 style="background:#A77763;color:#fff;padding-left:20px">Please Fill The Form to Contact us We Would Like to hear from you</h2>
<form id="form1" method="post" action="">
               <table width="560" class="form_enquiries">
                <tr>
                  <td width="215" valign="top">&nbsp;</td>
                  <td width="333">&nbsp;</td>
                </tr>
                <tr>
                  <td valign="top">Surname:</td>
                  <td><input type="text"  class="input_text" name="surname" id="surname" /></td>
                </tr>
                <tr>
                  <td valign="top">Othernames</td>
                  <td><label for="othernames"></label>
                  <input type="text"  class="input_text" name="othernames" id="othernames" />
                  *</td>
                </tr>
                <tr>
                  <td valign="top">Contact Number</td>
                  <td><input type="text"  class="input_text" name="contact_num" id="contact_num" /></td>
                </tr>
                <tr>
                  <td valign="top">Email :</td>
                  <td><input type="text"  class="input_text" name="email" id="email" />
                    *</td>
                </tr>
                <tr>
                  <td valign="top">Profession:</td>
                  <td><label for="prof"></label>
                  <input type="text"  class="input_text" name="prof" id="prof" /></td>
                </tr>
                <tr>
                  <td valign="top"> Organisation:<br /></td>
                  <td><label for="org"></label>
                  <input type="text"  class="input_text" name="org" id="org" /></td>
                </tr>
                <tr>
                  <td valign="top">Country:</td>
                  <td><label for="country"></label>
                    <select name="country" id="country" class="select">
                  </select></td>
                </tr>
                <tr>
                  <td valign="top">Purpose / Reason :</td>
                  <td><textarea name="comment" id="comment" cols="30" rows="10" class="text_area"></textarea>
                    *</td>
                </tr>
                <tr>
                  <td valign="top">How did u locate us?</td>
                  <td><p>
                    <label>
                      <input type="radio" name="how_u_located_us" value="friend" id="how_u_located_us_0" />
                      Friends</label>
                    <label>
                      <input type="radio" name="how_u_located_us" value="online" id="how_u_located_us_1" />
                      Online Ad</label>
                    <label>
                      <input type="radio" name="how_u_located_us" value="newspaper" id="how_u_located_us_2" />
                      Newspaper</label>
                    <br />
                  </p></td>
                </tr>
                <tr>
                  <td valign="top">&nbsp;</td>
                  <td><input type="submit" name="m4submit" id="m4submit" value="Contact Us" class="btn"/></td>
                </tr>
                <tr>
                  <td valign="top">&nbsp;</td>
                  <td>&nbsp;</td>
                </tr>
                <tr>
                  <td valign="top">&nbsp;</td>
                  <td>&nbsp;</td>
                </tr>
              </table>
</form>
